HONOLULU -- Treating ventilator-associated tracheobronchitis in the ICU before it progresses to pneumonia may improve outcomes, researchers said here.

Action Points

Explain to patients who ask that the small study needs to be replicated before routine screening and treatment could be recommended for ventilator-associated tracheobronchitis in the ICU.

This study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.

HONOLULU, Feb. 7 -- Treating ventilator-associated tracheobronchitis in the ICU before it progresses to pneumonia may improve outcomes, researchers said here.

Antibiotic treatment was associated with a substantially lower rate of subsequent ventilator-associated pneumonia and more than halved the rate of mortality in the ICU, reported Saad Nseir, M.D., of Calmette Hospital in Lille, France, and colleagues at the Society of Critical Care Medicine meeting.

These findings from a small randomized controlled trial reflect more aggressive screening and treatment for tracheobronchitis than done in many ICUs, commented Stephen M. Pastores, M.D., of the Memorial Sloan-Kettering Cancer Center in New York, who moderated the session at which the results were presented.

"Certainly at our place we don't routinely screen for this," he said. "We're always worrying about ventilator-associated pneumonia, we're not thinking of tracheobronchitis."

However, there may be a continuum between microbial colonization, tracheobronchitis, and pneumonia that argues for early treatment such as that used in the study, Dr. Nseir said.

"Maybe this is real; maybe we should be screening," Dr. Pastores said, but at any rate the improved outcomes suggest that treatment is needed for cases that are identified.

"We should not wait to treat [until ventilator-associated pneumonia sets in]," he said.

The prospective multicenter study randomized 22 patients to receive intravenous antibiotics for eight days and 36 to receive no antibiotics before the trial was stopped early for efficacy at a planned interim analysis.

Those with prior ventilator-associated pneumonia, do-not-resuscitate orders, or severe immunosuppression, or who received antibiotics for other infections after being randomized to no antibiotics, were excluded.

The specific antibiotics were selected for each patient on the basis of results of microbial testing. Pseudomonas aeruginosa was the most commonly isolated bacteria, followed by Staphylococcus aureus, but all were found in similar proportions between treatment groups.

The duration of mechanical ventilation overall was similar between groups (29 versus 26 days, P=0.81). But the number of days alive without mechanical ventilation was substantially greater with antibiotic treatment (12 versus two, P<0.001).

Antibiotic-treated patients were also more than three times less likely to go on to develop ventilator-associated pneumonia (13% versus 47%, OR 0.17, P=0.011), supporting the idea that untreated tracheobronchitis could lead to pneumonia in the ICU, Dr. Nseir noted.

He cautioned, though, that the study was unblinded and the sample size was small. "We need larger studies to change our day-to-day practice," he said.

Furthermore, he said diagnosis was difficult. Baseline CT imaging was not available in the study but may not be practical for all ICU patients at any rate, he noted.

The findings are likely generalizable to other countries, Dr. Pastores said, although larger studies would be needed, particularly because of concerns over microbial resistance from overuse of antibiotics.

The study was supported by the Program Hospitalier de Recherche Clinique. Dr. Nseir reported no conflicts of interest. Dr. Pastores reported no relevant conflicts of interest.

Reviewed by Zalman S. Agus, MD Emeritus Professor University of Pennsylvania School of Medicine

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